HEALTH CARE HOME Corey Lakins, Project Director

1. HEALTH CARE HOME Corey Lakins,Project Director MILESTONE CENTERS INC. SQURRIL HILL HEATH CENTER COHORT 2 LEARNING COMMUNITY REGION 5 PITTSBURGH, PA clakins@milestonecentersinc.org 412-371-3791 ext 117

2. ABOUT OUR PROGRAMHEALTHCARE HOME (HCH) • Integration Model • Two out of three sites have integrated treatment teams where the mental health, primary care provider and HCH team comes together and discuss the consumer’s P/BH treatment plan. • The team consist of the psychiatrist, primary care physician, clinicians, RN, care navigators and administrators. • The integrated teams meet once a month. • Strategies used to incorporate primary care • Milestone already had an existing relationship with SHHC. • Enrollment target • 168 (70% =118 for FFY 2012). Currently served 96 consumers. • Special populations served • SPMI, IDD and Deaf consumers.

3. ABOUT OUR PROGRAMHEALTHCARE HOME (HCH) • Milestone’s two sites are suburban setting • Certified Peer Support role: • Co-facilitate and facilitate groups, transports consumers to specialty doctor appointments, home visits, individual peer support, escort to mobile medical van and reminder call for all appointments • EHR Vendor is Qualifacts • Upgraded to ONC-ATCB certified version December 2011 • Unique: We provide primary care and wellness services to deaf consumers. PCP is ASL fluent.

4. WHO ARE WE?“Staffing structure” • (1) RN – provides non acute interim patient visits, routine screenings and oversees wellness services. Milestone M-F. • (2) Care Navigators – enrollments, assessments/reassessments, provides linkage within healthcare system. • (1) Health and Wellness Educator – facilitates wellness groups. • (1) Peer Support Specialist – co facilitate/facilitates groups, transport consumers and provides individual peer support. • (1) Project Director – oversees project. • (2) Primary Care Physicians – MOU with SHHC (FQHC) • Medical Director, Internal Medicine and Geriatrics (SHHC) • Family Practice Physician – ASL (SHHC) • (1) Physician assistant (SHHC)

6. SUCCESSFUL STRATEGIES“Wellness consumer story” • Strategy – Making the connection with consumers as a TEAM! • Results/Outcomes HCH Interview for the Key – Amanda A What have you found helpful in the Health Care Home Program? I really liked the wellness group activities, of course, and the variety of activities that you have. Some of them are structured for managing different aspects of your life, some are educational, some are relaxing, and some are just fun to get together at. The social aspect is good for me because I am a bit of a loner. The group facilitators are really awesome, some of the best I have had actually. And I find that in this program that the facilitators have got it so together compared to other clinics. If I didn’t have you guys, I would feel a lot more lost than I do, especially when I am not feeling the best. When I am not feeling the best I have something to look forward to, like on Tuesday I have a Stress Reduction group. Even if I am not really feeling well enough to groove into the activities at least there are people and a facilitator that I know and I can at least be in proximity of. What would you tell others about your personal experience with the Health Care Home team? I would say that the team is the best team I have had in either Australia or the United States. Honestly, and it’s not even like one of the well known mental health centers. But, when I left another (more well known) place, they left me for one month after inpatient without a doctor. It’s really amazing how Health Care Home has brought me out of my shell and got me into the community more, too. Because I am really not that kind of person. It is something that I have explored that is a side of me that maybe was there but I wasn’t sure I had. It has helped my self esteem a lot. The level of experience of the (wellness group) facilitators (and care manager), Adrienne and Ken-netta, they maintain the dignity of the patients and the integrity of the group. They are very energetic and engaging. Other groups sometimes you just want to drop out because there is no connection and it is a drag. Health Care Home makes you want to go along instead of thinking, “Oh no, I have a group to go to.”What additions would you like to see to the program? Probably, for me personally I’d like the groups to start a little later in the morning (laughs). With medicine sometimes it’s hard to get in by ten. As far as editions, a weekly group activity or outing. Or biweekly or monthly, something like that. I can’t really think of anything else. How has your mental well being changed as a result of getting your primary care services through Health Care Home? Definitely a lot better. I have definitely been more proactive. I am glad that Ken-netta and Janet are around. And I don’t know where I’d be if I didn’t have those wellness groups now really. I wasn’t doing anything and I started a different group and graduated from it. Then I decided to try one of your wellness groups. So, yeah, they are a life saver. In between therapy and seeing my psychiatrist, the groups are a really good support. I felt strange. I have bipolar disorder and it hit me like a brick when I was 26, and also I have a PhD, and here is me looking forward to the wellness groups. But, I really think the facilitator and design help me be able to do that. It keeps me in a routine and that is really important. It’s definitely awesome, I can’t even believe I have been blessed with these (wellness) groups, my therapist, my psychiatrist, and Health Care Home. I always have a support in place and good activities to have in between doctor and therapy visits. And they get you out of bed, too.

7. SUCCESSFUL STRATEGIES“enrollment/reassessment” • Strategy • Enrollments - Introduced a simple step: all consumers sign-in using a slip of paper. HCH added four questions: • Do you have a primary care physician? • Have you seen your primary care physician in the past 12 months? • Are you happy with your primary care physician? • Would you be interested in seeing a primary care physician here at Milestone? • Reassessments - consumer’s are scheduled in conjunction with other agency appointments. • Results/Outcomes • More than tripled our monthly enrollments • We catch every consumer that comes through the doors! • Re-assessment rate FFY 2011 was 100%. FFY 2012 to date is 77.8%

8. SUCCESSFUL STRATEGIES“Reduce your tobacco, reduce your habit”

9. PLANS FOR THE FUTURE • Sustainability • Clinical – we plan to continue our MOU with SHHC. Will need to look at baseline for encounters and what it will take to sustain services, i.e. shorter and more frequent visits. Average caseload needed per visit, etc. • Administrative – we will look at current positions and begin to analyze the structure for future needs and feasibility. • Financial – we will begin to assess billable services, what services medicare/medicaid will reimburse. Salary in comparison to reimbursable rate. • In the next 6 months we hope to have a good methodical plan in place where we can begin to put the pieces together for sustainability

10. MILESTONE“HEALTH CARE HOME PROJECT”THANK YOU!